Defeating Cholera: Clinical Presentation and Management

for Haiti Cholera Outbreak, 2010

Rapid high-volume rehydration will save lives

Many patients can be rehydrated entirely with oral rehydration solution (ORS)

Even if the patient gets intravenous (IV) rehydration, he/she should start drinking ORS as soon as he/she is able

SYMPTOMS OF MODERATE OR SEVERE CHOLERAProfuse, watery diarrhea

Vomiting Leg cramps

SIGNS AND SYMPTOMS OF DEHYDRATIONSome dehydration

Restlessness and irritability

Sunken eyes

Dry mouth and tongue

Increased thirst

Skin goes back slowly when pinched

Decreased urine

Infants: decreased tears, depressed fontanels

Severe dehydration

Lethargy or unconsciousness

Very dry mouth and tongue

Skin goes back very slowly when pinched (tenting)

Weak or absent pulse

Low blood pressure

Minimal or no urine

Most persons infected with the cholera bacterium have mild diarrhea or no symptoms at all. Only about 7% of persons infected with Vibrio cholerae O1 have illness requiring treatment at a health center.

Cholera patients should be evaluated and treated quickly. With proper treatment, even severely ill patients can be saved. Prompt restoration of lost fluids and salts is the primary goal of treatment.

December 2010

2ORAL REHYDRATIONDehydrated patients who can sit up and drink should be given oral rehydration salts (ORS) solution immediately and be encouraged to drink. It is important to offer ORS solution frequently, measure the amount drunk, and measure the fluid lost as diarrhea and vomitus. Patients who vomit should be given small, frequent sips of ORS solution, or ORS solution by nasogastric tube. ORS solution should be made with safe water. Safe water means the water has been boiled or treated with a chlorine product or household bleach.

Guidelines for treating patients with some dehydration

Approximate amount of ORS solution to give in the first 4 hours to patients with some dehydration. Use the patients age only when you do not know the weight:

Age

3Signs of adequate rehydration Skin goes back normally when pinched

Thirst has subsided

Urine has been passed

Pulse is strong

INTRAVENOUS REHYDRATIONPatients with severe dehydration, stupor, coma, uncontrollable vomiting, or extreme fatigue that prevents drinking should be rehydrated intravenously.

Intravenous solutions

Best Ringers Lactate Solution

Acceptable* Normal saline*

Unacceptable Plain glucose (dextrose) solution*Acceptable in emergency, but does not correct acidosis and may worsen electrolyte imbalance.

Guidelines for treating patients with severe dehydrationStart intravenous fluids (IV) immediately. If the patient can drink, give ORS solution by mouth while the IV drip is set up. Give 100 ml/kg Ringers Lactate Solution divided as follows:

Age First give 30 ml/kg IV in: Then give 70 ml/kg IV in:

Infants (1 yr.) 30 minutes* 2 hours

* Repeat once if radial pulse is still very weak or not detectable.

Reassess the patient every 1-2 hours and continue hydrating. If hydration is not improving, give the IV drip more rapidly. 200ml/kg or more may be needed during the first 24 hours of treatment.

Also give ORS solution (about 5 ml/kg per hour) as soon as the patient can drink.

After 6 hours (infants) or 3 hours (older patients), perform a full reassessment. Switch to ORS solution if hydration is improved and the patient can drink.

4ANTIBIOTICSAn antibiotic given orally will reduce the volume and duration of diarrhea. Treatment with antibiotics is recommended for moderately and severely ill patients, particularly for those patients who continue to pass large volumes of stools during rehydration treatment, and including all patients who are hospitalized. Do not give antibiotics to asymptomatic persons. Zinc given orally can reduce the duration of most infectious diarrhea in children. No drugs besides antibiotics and zinc for treatment of diarrhea or vomiting should be given.

Appropriate oral antibiotics (give one of these) ** ALL BY MOUTH** These recommendations are based on the antibiotic resistance profile of V. cholerae isolates from the Haiti cholera outbreak, as reported on December 14, 2010, and local drug availability.

Multiple first choice and second choice options are presented. Selection of antibiotics should be based on individual case consideration and available medications.

Patient classification First choice Second choiceAdults (non-pregnant)

Doxycycline: 300 mg by mouth in one dose

Azithromycin:1 gram in a single dose

Tetracycline: 500 mg 4 times a day for 3 days

Erythromycin: 500 mg 4 times a day for 3 days

Pregnant women Azithromycin: 1 gram in one dose Erythromycin: 500 mg 4 times a day for 3 days

Children 12 months old and capable of swallowing pills and/or tables

Azithromycin: 20 mg/kg in one dose

Erythromycin: 12.5 mg/kg 4 times a day for 3 days

Doxycycline: 2-4 mg/kg in one dose*

Tetracycline: 12.5 mg/kg 4 times a day for 3 days

Children